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Chapter Ill Material & Methods

I
It
L.. ----- .-- - - .

MATERIAL AND METHODS

II

The present study was carried out in B.J. Medical College, Civil Hospital,
Ahmedabad from 2004 to October 2009. It was a cross sectional study and study
subjects comprised of outdoor and indoor patients of Civil Hospital and their
relatives. Adolescent subjects comprised of first year nursing students of Civil
Hospital and school girls from high school of east Ahmedabad. Patients and their
relatives were from the State of Gujarat and neighbouring states.
Subjects were randomly selected by stratified sampling method for the study.
Females from 10 to 49 years of age were divided in to three groups (strata) i.e.
adolescents, adult pregnant and adult nonpregnant females and samples were
randomly drawn from each strata. To study the prevalence and other
epidemiological features of nutritional anemia in study population females already
diagnosed of having anemia from outside were excluded. Subjects were from all
communities and from all socio-economic classes, from rural or urban areas,
having different levels of education and either students, housewives or working
females.
Exclusion Criteria :

1.

Females below 10 years and above 49 years of age.

2.

Females having other medical disease like Hypertension, Diabetes,


Thyroid disorders or any major systemic disease.

3.

Females on any regular drug therapy .

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4.

In pregnant patients, patients having any high risk factor like multiple
pregnancy, diagnosed fetal anomaly, grand multipara, uterine
anomaly, bad obstetric history, liquor abnormality were also excluded.

5.

Patients having gynec pathologies like fibroid, adenomyosis, ovarian


tumours were also excluded.

6.

Adolescent pregnant patients were excluded as adolescent period


and pregnancy both increase the chances of anemia.

Total 800 females were screened out of which 550 were adult females and 250
were adolescent girls. Among 550 adult females 350 were pregnant and 200 were
non pregnant. The anemia was diagnosed by clinical examination and confirmed
by hemoglobin estimation. Hb estimation was done

by Cyanmeth-hemoglobin

method and WHO criteria were used to diagnose anemia as follows:For Adult females and adolescents< 12.0 gm%.
For Adult pregnant females< 11.0 gm%.
Total 497 were diagnosed to suffer from anemia (62.12%). 52 subjects having
other types of anemia like hemolytic anemia (malaria, drug induced), hemorrhagic
anemia (hookworm, piles, menorrhagia) hemolytic anemia (Thalassemia, Sickle
Cell Disease) and aplastic anemia were further excluded as the aim was to study
the health hazards of nutritional anemia only. These other types of anemias were
diagnosed by history, clinical examination and necessary investigations.

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Total 445 females were having nutritional anemia i.e. 55.62% prevalence in the
screened population. Nutritional cause was investigated by doing laboratory
investigations in the form of serum iron, total iron binding capacity (TIBC) and
peripheral smear in all cases. Serum ferritin was done in all adolescent girls and
75% of adult females. Serum folic acid and serum vitamin 812 estimations were
done only in subjects having either severe anemias (Hb<7.0g%), or clinical
features of these vitamins deficiencies or detection of megaloblasts on peripheral
smear examination. Limitation in carrying out these special investigations in all the
subjects was due to financial constraints as these investigations were not done in
Civil Hospital Pathology Department and getting them done in private laboratory
involved high cost.
Total 445 subjects of nutritional anemia were studied in the present study by
dividing them in 2 groups. Group-1 of adolescent girls and Group-11 of adult
females.

To compare the health related hazards control subjects were taken in respective
groups. They were also taken randomly by stratified sampling method. Controls
were nonanemic females and in the same age group, residence, community and
similar socio-economic status. They were selected from patients' relatives in adult
females and colleague students in adolescent girls. The relatives in adult group
were daughter, sister, sister in law, daughter in law, mother and mother in law who
usually accompany the patients. Controls were taken of the same number in each
group for proper comparison.

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Group-1:

Group-11:

Adolescent girls between the age 10 to 19 years.


Group-1 A :

Anemic subjects

Group-1 B :

Controls

Adult Females between the Age> 19 to 49 years


Group II A :

Anemic subjects
II A-1 Pregnant patients
II A-2 Non pregnant females

Group II B: Controls
II B-1 Pregnant patients
II B-2 Non pregnant females
Group-1:

Total 216 adolescent girls were studied in this group. 108 in each
sub group I A and I B.

Group-11:

Total 674 adult females were studied in this group, 337 in each
sub group II A and group II B. Among 337 of each sub group II-A
and 11-B 228 were pregnant and 109 were non pregnant adult
females.

The study subjects were evaluated as per predesigned performa. To study the
spectrum of nutritional anemia in 445 anemic subjects epidemiological features
were analysed first. The detailed history was taken including age, religion,
education, residence and economic status of the family. Modified Prasad
Criteria

154

was used for classifying them in different economical class. They were

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divided in three classes from six of Prasad classification.

Their number in the

family i.e. birth order was noted. In adult females, whether they were housewives
or working was noted. Each anemic subject was assessed for the awareness
regarding anemia and dietary rich sources of iron and folic acid. Whether they
were knowing their Hb or not was also checked. Detailed dietary history was taken
keeping in mind about quality, quantity and iron and folic acid components of diet.
Menstrual history was taken in detail. Regularity of the periods, number of days of
bleeding and amount of flow was asked.- As mentioned earlier cases of
menorrhagia were excluded as menorrhagia and anemia has cause and effect
relationship, making it difficult to establish which occurred first in a particular
female.
In married females the obstetric history was taken in detail. Gravidity, parity, full
term delivery, preterm deliveries and abortions were noted. History of any obstetric
complications in past pregnancies were elicited.
Further study was carried out for assessment of health related hazards in these
nutritional anemic subjects and compared with appropriate controls. Adolescent
subjects were analyzed separately from the adult subjects by dividing them into
Gr.l and Gr.ll for health related hazards.
General health was assessed by weight and height examination and body mass
index (BMI) was calculated by the standard formula i.e. BMI = Kg/M 2 Symptoms
of anemia like weakness, tiredness, dizziness, headache, irritability was checked
by asking leading questions.

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History of infections like respiratory infection, urinary tract infections, genital tract
infections and gastrointestinal tract infections in last five years was elicited in
details by asking subjects themselves or their relatives and checked by available
records. History of repeated infections was also checked.
Physical capacity was assessed by asking their efficiency to do work at home or at
the job place. Diminished efficiency or any limitation to do routine work was
recorded. For housewives doing three of five home tasks i.e. cooking, sweeping
the house, washing cloths, cleaning utensils and miscellaneous household work
without fatigue was considered normal. For working women their job + one
household task and for adolescent girls study + one household task without any
limitation was considered normal.
Cognitive performance by IQ testing was assessed by asking them to answer a
standard set of 40 questions taken from the I Q tests questions prepared by
vocational guidance institute Government of Gujarat. 155 Four points was given for
each correct answer and total score was calculated. Score below 40 was
considered as poor IQ, 40 to 80 as average IQ, 80 to 120 as good IQ and 120 to
160 as genius. Time required to complete the 40 questions was also noted in full
minutes. For illiterate patients mathematical questions were not asked. English
translation of complete document with 50 questions (40 were used) is given at the
end in Annexure I.
In pregnant subjects obstetric outcome was assessed by following them till delivery
and six weeks postpartum. Maternal morbidity was assessed. Puerperal pyrexia
including puerperal sepsis, post partum hemorrhage (PPH), congestive cardiac

38

failure (CCF), wound complications and failure of lactation were recorded in


anemic as well as control subjects.
Perinatal morbidity was recorded. Cases of birth asphyxia, prematurity, intra
uterine growth restriction, neonatal sepsis and other neonatal complications were
recorded. Perinatal deaths in the form of still births and neonatal deaths were
analysed for cause of death in both anemic as well as control subjects.
Treatment: Counselling was done to all445 anemic subjects regarding dietary rich
sources of iron and folic acid and to change their dietary habits. As iron deficiency
was found on investigation, in all anemic subjects iron was administered to all .
Patients with mild anemia were treated by oral iron ferrous sulphate 200 mg tablets
which contains 60 mg elemental iron. Patients with moderate anemia were treated
by either oral iron or parenteral iron followed by oral iron particularly when Hb was
less than 8 gm%. Iron sucrose intravenously was used for parenteral iron therapy.
Iron sucrose is safe and gives rapid rise of Hb. Its dose is considered by the
formula. Weight (in kg) x Hb deficit in gram (12 actual Hb) x 0.24 + 500 mg. 100mg
IN was given on alternate days diluted in 100 ml of normal saline.
Folic acid 0.5 mg was given to all pregnant patients and 5 mg to subjects with folic
acid deficiency.
Anemic subjects with severe anemia were directly treated with blood transfusion in
the form of packed cell volume, number of PCVs were determined by her original
Hb and aim was to raise the Hb to at least 9 gm%. One unit of packed cells raises
the Hb by approximately 1 to 1.5 gm%.

39

----------------------------------------

Statistical analysis was done in terms of percentage, Chi square test, Z test and P
values were obtained for statistical significance using Epi Info software as
mentioned in results under individual table.

PROFORMA : NUTRITIONAL ANEMIA

Date:

Sr. No.
Name:

OPD/Indo. No.

Education: UE/Pri/Sec/Grad/PG

Age:

Religion : Hindu I Mus I Christ /Others


M/H : Menarche :
No. of pads

Residence: Rural/Urban

Occupation :

PaMP :

S.E.Status :

LMP :

H/o. clots

OIH:
Contraception :
Gen.Health : Weight :
Diet : VegiNon Veg.
Iron rich foods:

Height:

BMI:

Calories : Adequate I nonadequate


Cereals I pulses I fruits I green vegetables I Jaggery
Non-veg.

F.A. Rich : Green vegetables


Food habits :
Awareness : About anemia & Diet : Yes I No
About their Hb: Yes I No
Her No. in the family :

40

Work efficiency : Student : Normal/ Reduced


At work place : Normal/ Reduced
At home : Normal/ Reduced
Complaints: Fatigue ,Weakness,Dizziness,Breathlessness,Headache,Others
H/0 Infections :

UTI : one episode /more


RTI : one episode /more

IQ score:

Genital tract : one episode /more


G I tract : one episode /more

Time required :

Investigations:

Hb:

TIBC:

Se. Iron :

Peri.Smear : MP

MCV:

MCH:

Se.Ferritin

Se.Folate

Se. Vitamin 812

Stool

Urine

MCHC:

Others

Other anemias : Malaria I worms I piles I Congenitai/Hemolytical


Obst. Outcome :

Mother : Sepsis I CCF I Wound gap I death I others


New Born : M/F

Wt.

Maturity

Complication:

Treatment : Oral iron I iron + Folic Acid


Parenteral iron I Parent iron + Oral
PCV.
Follow up:
Remarks:

41

Chapter IV Results

RESULTS
Table No.1 :Age distribution of anemic subjects
No. of subjects

No. of subjects

Adolescent

Adult

10-19

108

108 (24.3)

20-29

168

168 (37.7)

30-39

98

98 (22.0)

40-49

71

71 (16.0)

337

445 (100.0)

Age in years

108

Total(%)

More than 1/3rd of anemic subjects were in third decade (37.7 %) , more or less

1/4th of subjects (24.3%) were in the second decade, while less than 1/4th (22.0%)
were in the 4th decade. Mean age of study subjects was 27.19 9.5. At 95 %
Confidence limit Confidence interval was 8.57 to 45.81.

Table No. 2 : Educational Status


Education

Adolescents ( % )

Adults (%)

Graduate or post
graduate

62 (18.4)

High school
HSC/SSC passed

73 (67.6)

79 (23.4)

Primary School

35 (32.4)

126 (37.4)

161 (36.2)

Illiterate

70 (20.8)

70 (15.7)

Total

108 (100.0)

337 (100.0)

445 (100.0)

Total (%)

62 (13.9)
152 (34.2)

The education in adolescents was HSC or SSC in 2/3rd of subjects (67.6 %), while
more or less 1/3rd (32.4%) were studying in schools. One third of adult subjects

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(37.4%) were having primary school education, while less than 1/41h (23.4%) were
having HSC/SSC level education. Anemia was prevalent in all, adolescent and
adult anemic subjects irrespective of their education.

Table No. 3 : Residence


Residence

Adolescents(%)

Adults(%)

Total(%)

Rural

22 (20.4)

137 (40.6)

159 (35.7)

Urban

86 (79.6)

200 (59.4)

286 (64.7)

Total

108 (100.0)

337 (100.0)

445 (100.0)

Nearly 2/3rd (64.7%) of anemic subjects coming to civil Hospital were from urban
areas while more than 1/3rd (35.7%) of anemic subjects were from rural areas. As
per census of India 2001, 72.2 % of population resides in rural area while 27.8 %
stay in urban areas. Rural:urban ratio in present study is different from the last
census of 2001, because the Civil Hospital is a tertiary care teaching hospital in
the state of Gujarat and the patients are mainly from urban areas (>80%). In the
school and nursing students overall 15 % were from rural areas.

Table No. 4 : Different Communities


Community

Adolescents(%)

Adults(%)

Total(%)

Hindu

90 (83.3)

252 (74.8)

342 (76.8)

Muslim

12 (11.1)

68 (20.2)

80 (18.0)

Christian

6 (5.6)

17 (5.0)

23 (5.2)

Total

108 (100.0)

337 (100.0)

445 (100.0)

43

More than 3/41h (76.8%) number of anemic subjects were hindus, while less than
1/41h (18.0%) were muslims. It is matching with the distribution of various
communities as per census of 2001. As per census of India 2001, 80.5 % are
hindus, 13.5 % are muslims and 2.3 % are christians. Thus religion had no
influence on prevalence of nutritional anemia. All subjects other than Muslim and
Christian like Sindhis and Sikhs were included in Hindus.

Table No. 5 : Diet


Diet

Adolescents (%)

Adults(%)

Total(%)

Vegetarian

82 (75.9)

231 ( 68.5)

313 (70.3)

Non-vegetarian

26( 24.1)

106 (31.5)

132 (29.7)

Total

108 (100.0)

337 (100.0)

445 (100.0)

More than 2/3rd (70.3%) anemic subjects were purely vegetarian. Only less than
1/3rd (29.7%) were taking mixed diet, hence labeled as non-vegetarians. On
detailed analysis it was found that all these 132 (26+1 06) non-vegetarian subjects
were consuming less than one non-vegetarian meal per week.
According to the 2006 survey 156 40 % of population in India is vegetarian. In this
study vegetarians were more than non-vegetarians not matching with the national
data at large because the state of Gujarat is having more vegetarians than other
states.

44

--

---------------------

Table No. 6 : Occupation


Occupation
Student

Adolescents (%)

Adults(%)

108 (100.0)

Housewife

Total(%)
108 (24.3)

157 (46.6)

157 (35.3)

84 (24.9)

84 (18.9)

96 (28.5)

96 (21.5)

108 (100.0)

337 (100.0)

445 (1 00.0)

Working
Office type table work
Labourer
Total

Nutritional anemia was prevalent in all types of females - students, working and
housewives. More than 40 % of anemic subjects were working in present study,
while female working population at large is 25.6 % as per census 2001. As the
anemic subjects were more from urban areas where most of the females also
work, the working anemic subjects were more than the census 2001.
Table No. 7 : Economic status of 445 anemic subjects
Modified Prasad Classification
Socia Economic Class

Adolescents(%)

Adults (%)

Total(%)

Upper

16 ( 14.8)

42 (12.5)

58 (13.0)

Middle

28 (25.9)

80 (23.7)

108 (24.3)

Lower

64 (59.3)

215 (63.8)

279 (62.7)

Total

108 (100.0)

337

445 (1 00.0)

Only three main categories were taken from original six classes of Prasad
classification. Most of the anemic subjects were from lower socioeconomic (SE)
group (62.7%), while approximately 1/4th (24.3%) were from middle SE group. It
shows that economic status of subjects play a role in nutritional anemias. Lower

45

SE group included 154 (34.6%) below poverty line (BPL) and 125 (28.1%) poor
economic class subjects. As per Planning Commission of India population below
poverty line reported is 27% in 2005.
Table No. 8 : Birth Order

Birth order

Adolescents(%)

Adults(%)

Total(%)

1st

33 (30.6)

63 (18.7)

96 (21.6)

2nd

31 (28.7)

75 (22.3)

106 (23.8)

3rd

24 (22.2)

97 (28.8)

121 (27.2)

41h or more

20 (18.5)

102 (30.3)

122 (27.4)

Total

108 (100.0)

337 (100.0)

445 (1 00.0)

Birth order is not showing any important correlation with anemic subjects in the
present study. Nutritional anemia was prevalent whether the study subject was a
first child in the family or second, third, fourth or more in number in her family.
Fig. No. 9 : Knowledge regarding anemia, diet and their Hb
9 A : Knowledge about anemia and dietary sources of iron & folic acid

Category

Adolescents ( % )

Adults (%)

Total (%)

Not knowing

79 (73.1)

206 (61.1)

285 (64.0)

Knowing

29 (26.9)

131 (38.9)

160 (36.0)

Total

108 (100.0)

337 (100.0)

445 (100.0)

Chi Square 5.14

p = 0.023

Overall 64% females (285 out of total 445) had no knowledge about anemia and
dietary rich sources of iron. This was statistically significant. (P < 0.05). It was more
in adolescents (73.1 %) than in adult subjects (61.1 %).

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9 8 : Knowledge about their Hb

Category

Adolescents ( % )

Adults (%)

Total (%)

No

92 (85.2)

229 (68.0)

321 (72.1)

Yes

16 (14.2)

108 (32.0)

124 (27.9)

Total

108 (100.0)

337 (1 00.0)

445 (1 00.0)

Chi Square 12.08

P = 0.0005

Overall 72.1% females ( 321 out of total 445) were not knowing their own Hb. This
was statistically significant. (P < 0.05). It was quite more in adolescent group
(85.2%) as compared to adults (68.0%). This may be due to adult females might
have undergone Hb estimation during their past pregnancies.
Table No. 10 : Degrees of anemia

Degree
Mild

Hb level

Adolescents.(%)

Adults (%)

Nonpregnant

10 to <12.0 g%

57 (52.8)

67 (19.9)

Pregnant

10 to <11.0 g%

121(35.9)

7 to <10 g%

47 (43.5)

113 (33.5)

160 (36.0)

< 7.0 g%

4 (3.7)

36 (10.7)

40 (9.0)

108 (100.0)

337 (1 00.0)

445 (100.0)

Moderate
Severe
Total

Total (%)
245 (55.0)

Mild anemia is found in more than 50% cases in both the groups. While severe
anemia is more common in adult group. Most of these (33 out of 36) were
pregnant subjects. In moderate anemia group there were 36 patients (out of total
160 subjects) were having Hb less than 8.0 Gm%.

47

Other Investigations :
Fig. No. 1 : Serum iron values

Se.iron ug/dl

80 .-------------. --------------------------------70

1~~~

6o

so"~$~~~!"~*'~
~~. ~~~ ~~~.
~ ....
fi~"
'
.. .

40
~Vi
~
30 r"".
..l~,.
~
~-
20 +
~

-----l

'I
!

Ii

1o

l
0+---------------~----------------,-------~
0

100

200

300

400

500

no. of subjects

Fig.No.1 shows scatter diagram of serum iron values in 445 anemic subjects
Serum iron was ranging from 24 to 68 ).lg/dl in adolescents and 20 to 54 ).lg/dl in
adult subjects (normal range 60-150 ).lg/dl).
TIBC was ranging from 360 to 500 ).lg/dl in adolescents and 380 to 590 ).lg/dl in
adults subjects (normal range 250 to 350 ).lQ/dl). Peripheral smear was done in all
cases and showed microcytic hypochromic ( iron deficiency ) or dimorphic anemia
( iron +folic acid deficiency) picture.

48

!~
Fig. No. 2 : Serum Ferritin values

Se.Ferritin ug/1

90
80

70

60
50
40
30 #.
20

10
0

~--~----~----~---,-----,--------~~--~

50

100

150

200

250

300

350

400

No. of subjects

Fig. No.2 shows scatter diagram of serum ferritin values. It was done in total 362
subjects - all adolescents and 75% of adult subjects. In both the groups it was
ranging from 8 to 80 ug/1. In most of them it was less than 30 ug/1.
Serum Folate and serum Vitamin 812 was done in 71 subjects who were having
either severe anemia or clinical features of their deficiencies or megaloblasts
detected on peripheral smear. 31 anemic subjects were having low folate levels
ranging from 1.2 to 3.0 ng/ml, while Vitamin B 12 levels were in normal range
except three cases they were marginally low ( 190-200 pg/ml ).
Table No. 11 : Symptoms

Leading questions regarding symptoms of anemia like tiredness, weakness,


dizziness, feeling of chromic ill heath were asked to the anemic subjects as well as
controls.

49

------------------

--------

11 A : Adolescents

Symptoms

Gr I A. Anemic
subjects (%)

Gr I B. Controls (%)

Present

64 (59.3)

24 (22.2)

Absent

44 (40.7)

84 (77.8)

Total

108 (100.0)

108 (100.0)

Chi Square 30.6

P = 0.0000

11 B: Adults

Symptoms

Gr II A. Anemic
subjects(%)

Gr II B. Controls (%)

Present

266 (78.9)

114 (33.8)

Absent

71(21.1)

223 (66.2)

Total

337 (100.0)

337 (100.0)

Chi Square 59.1

P = 0.0000

The symptoms were present in 330 (74.1%) of anemic subjects (64 adolescents +
266 adults) while they were present in only 138 (31. 0%) of controls. (24
adolescents +114 adults) . Comparing both the groups of anemic subjects with
appropriate controls this was statistically significant (P<0.05) .

Table No. 12 : Weight


12 A : Adolescents
Weight in Kgs.

Gr I A. Anemic subjects ( % )

Gr I B. Controls ( % )

~40

37 (34.3)

35 (32.4)

41-50

64 (59.3)

63 (58.3)

51-60

6 (5.5)

8 (7.4)

61-70

1 (0.9)

2 (1.9)

Total

108(100.0)

108(100.0)

Chi Square o.68

P = 0.8

50

------------

12 B: Adults
Weight in Kgs.

Gr II A. Anemic subjects ( % )

Gr II B. Controls ( % )

~40

39 (11.6)

38 (11.3)

41-50

44 (13.1)

44 (13.1)

51-60

124 (36.8)

120 (35.6)

61-70

82 (24.3))

86 (25.5)

> 70

48 (14.2)

49 (14.5)

Total

337 ( 100.0)

337 ( 100.0)

Chi Square 0.18

P = 0.9

There was no significant difference (P > 0.05) in anemic subjects and controls as
far as the weight was concerned in both adolescents as well as adult groups. In
Gr I of adolescent subjects there was no student of > 70 Kg weight.

Table No. 13 : Body Mass Index (BMI)


13 A : Adolescents
Body Mass Index ( BMI)

Gr I A. Anemic subjects ( % )

Gr I B. Controls ( % )

< 18.50 Kg/M 2

31 (28.7)

26(24.1)

18.5 - 24.99 Kg/M 2

59 (54.6)

61 (56.5)

~ 25.00 Kg/M

18 (16.7)

21 (19.4)

108 ( 100.0)

108 ( 100.0)

Total

Chi Square 0. 7

p =0.7

13 B: Adults
Body Mass Index ( BMI)

Gr II A. Anemic subjects ( % )

Gr II B. Controls ( % )

< 18.50 Kg/M 2

40 (11.9)

38(11.3)

18.5 - 24.99 Kg/M 2

151 (44.8)

143 (42.4)

~ 25.00 Kg/M

146 (43.3)

156 (46.3)

Total

337 ( 100.0)
Chi Square 0.6

337( 100.0)

P = 0.7

51

----------

There was no significant difference (P > 0.05) in anemic subjects and controls as
far as BMI was concerned in both the groups. BMI categories were made
according to WH0 157 . BMI of< 18.50 Kg/M 2 are considered underweight, 18.50 to
24.99 Kg/M 2 are considered normal and .:::_ 25.00 Kg/M 2 are considered overweight.
This means that anemia can still be there even if other nutrition is not affected.

Table No. 14: Physical Performance


14 A: Adolescents
Gr I A. Anemic subjects ( % )

Gr I B. Controls ( % )

Reduced Capacity

70 ( 64.8)

44(40.7)

Normal

38 ( 35.2)

64 ( 59.3)

Total

108 ( 100.0)

108(100.0)

Chi Square = 12.56

p = 0.0004

14 B: Adults

Gr II A. Anemic subjects ( % )

Gr II B. Controls (%)

Reduced capacity

217 (64.4)

174(51.6)

Normal

120 (35.6 )

163(48.4)

Total

337( 100.0)

337 ( 100.0)

Chi Square

=11.26

p = 0.0008

In both the groups physical capacity was reduced in anaemic subjects as


compared to controls which was statistically significant (P < 0.05) . In adult group
physical capacity was reduced even in 51.6% of control group. This may be due to
physiological changes of pregnancy in pregnant subjects of the group (228 of 337).

52

Table No. 15 : Infections in last 5 years


15 A : Adolescents
Category

Gr I A. Anemic subjects (%)

Gr I B. Controls (%)

No infection

4 ( 3.7)

25 ( 23.1 )

One episode

78 ( 72.2)

66 ( 61.1 )

> 1 episode

26 ( 24.1 )

17 ( 15.8)

Total

108 (100.0)

108 (100.0)

Chi Square= 17.57

=0.00003

15 8: Adults
Category

Gr II A. Anemic subjects(%)

Gr II B. Controls(%)

No infection

36 ( 10.7)

78 ( 23.2)

One episode

211 (62.6)

198 ( 58.7)

> 1 episode

90(26.7)

61(18.1)

Total

337 (100.0)

337 (100.0)

Chi Square = 18.62

p = 0.00002

Infection in last 5 years was assessed by eliciting histories and by checking


available records in anemic subjects as well as controls. In Group I of anemic
adolescents 104 (78+26) had one or more episodes of infection while only 83
adolescents of control group (66+17) had history of infections in last 5 years.
In Group-11 of adults 311 anemic subjects had one or more episodes of infection as
against 259 subjects of controls. In both the groups this was statistically significant
(P< 0.05). In adolescents respiratory and gastrointestinal tract infections were

common while in adults genital tract and urinary tract infections were common. In
pregnant anemic subjects respiratory tract infections was also common.

53

Table No. 16: I Q Testing


16 A : Adolescents
Score

Gr I A. Anemic subjects ( % )

Gr I B. Controls ( % )

40

31 (28.7)

18(16.7)

> 40-80

66 ( 61.1 )

59 ( 54.6)

> 80-120

8(7.4)

18 ( 16.7)

> 120-160

3 ( 2.8)

13 ( 12.0)

Total

108(100.0)

108 ( 100.0)

Chi Square = 13.94

p = 0.003

16 B: Adults
Score

Gr II A. Anemic subjects ( % )

Gr II B. Controls (%)

40

98 ( 29.1 )

52 ( 15.5)

> 40-80

206 ( 61.1 )

200 ( 59.3)

> 80-120

22 ( 6.5)

56 ( 16.6)

> 120-160

11 ( 3.3

29 ( 8.6)

337 ( 100.0)

337 ( 100.0)

Chi Square = 15.54

p = 0.0014

I Q score obtained in both the groups were low in anemic subjects as compared to
controls & this was statistically significant (P < 0.05).
Anemic subjects were slow in completing the test. Time required in anemic
subjects ranged from 17 to 24 minutes with mean of 20.99

. 2.8 minutes ( 95

Confidence interval 18.19 to 23.79 ), while in controls it ranged from 13 to 21


minutes with mean of 16.0
19.78)

.:t

3.78 minutes (95 % Confidence interval 12.22 to

On applying the 'Z' test for comparison of anemic subjects with controls

for IQ test time it was statistically significant . P < 0.05 , Z = 43.85.

54

Table No. 17: Pregnant patients Maternal Outcome

Complications

Pregnant anemic subjects


Gr li.A.1

Controls
Gr II.B.1

Post partum hemorrhage

14

Congestive cardiac failure

Puerperal pyrexia
(includes sepsis)

24

Wound complications

Lactation failure

Total

57 (44)

17 (12)

Chi Square

=20.85

p = 0.00001

Total 44 patients of nutritional anemia had some obstetric complications as against


12 patients of control group. Total number of complications are more as some
patients had more than one complication. This was statistically significant
(P < 0.05).
Complications occurred because anemic subjects who were on treatment either
delivered before treatment was over or they suffered more blood loss during
delivery. Post partum hemorrhage (PPH) is common in anemic subjects as
myometrial oxygenation may be poor, resulting in atony of uterus and PPH.
Moreover moderate amount of blood loss can be detrimental to anemic patients.
Congestive cardiac failure occurred in patients of severe anemia in 2 during
labour, in 1 postpartum and in 1 when she was given Packed cells.
There was no case of maternal mortality in anemic subjects as well as controls in
present study.

55

Table No. 18 : Perinatal Outcome


18 A : Perinatal Morbidity

Complications

Pregnant anemic subjects


Gr II.A.1

Controls

Birth asphyxia

18

Prematurity

22

IUGR

25

10

Neonatal Sepsis

Others

Total

77 (68)

31 (26)

Chi Square= 17.66

Gr 11.8.1

p = 0.00003

Total 68 babies in anemic subjects and 26 babies in control group had one or more
complications. This was statistically significant (P < 0.05) As some of the newborns
had more than one complication total No. of complications is more than the
number of babies. Different complications were nearly 2 to 3 times more common
in anemic subjects as compared to controls.
18 B : Perinatal Mortality
Pregnant anemic subjects
Gr II.A.1

Controls
Gr 11.8.1

SB (Intrapartum)

Neonatal Death

11

4
5
2

2
3
0

11

Cause of Death
Prematurity
Severe birth asphyxia
Septicemia
Total

Chi Square = 2.33

p = 0.13

56

Perinatal deaths were more than double in anemic subjects as against controls but
this was statistically not significant.(P > 0.05) Neonatal deaths were common and
prematurity and severe birth asphyxia were the common causes.

Table No. 19: Treatment


Treatment

Failure

Side effects

Oral Iron

369

31( 8.4%)

108 ( 29.3%)

Parenteral Iron

36 + 31

Packed cells

40

Folic acid

235

All patients of mild anemia were treated by oral iron ferrous sulphate 200 mg tablet
per day. Patients having moderate anemia with Hb more than 8 gm% were also
treated by oral tablets but dose was increased to two tablets I per day. Parenteral
iron in the form of intravenous iron sucrose was given to the patients of moderate
anemia whose original Hb was less than 8 gm% ( 36) and 31 subjects in whom
oral iron therapy failed to raise their Hb at the end of 4 weeks.
Blood transfusion in the form of Packed cells was given to 40 anemic subjects
whose Hb was < 7 gm% i.e. severe anemia.
Folic acid tablets were given to all pregnant patients as supplements 0.5 mg/day
and 5 mg/day was given to all the 31 subjects having their deficiencies. Three
patients of Vit B 12 deficiency were treated by Vit B 12 JIM injections.
108 patients on oral therapy had side effects in the form of gastric upset,
constipation, diarrhoea.

57

-~-----------

Two patients on parenteral iron therapy had side effects of whom one had
induration at injection site and other developed minor allergic reaction to IV iron
sucrose. Two patients of blood transfusion had complications. One had CCF and
other had pyrexic reaction both were tackled effectively.

58